What is the acute stroke protocol for management and treatment?

Acute Stroke Protocol for Management and Treatment

The acute stroke protocol requires rapid assessment, imaging, and treatment with intravenous alteplase within 60 minutes of hospital arrival for eligible patients, followed by consideration for endovascular thrombectomy in those with large vessel occlusions. 1

Initial Recognition and Response

• Use validated stroke screening tools like FAST (Face, Arm, Speech Test), Los Angeles Prehospital Stroke Screen, or Cincinnati Prehospital Stroke Scale to rapidly identify potential stroke patients 1, 2
• Call emergency services immediately if any stroke signs are present, as even a single abnormality on screening has a 72% probability of indicating stroke 2
• Note the exact time of symptom onset (last known well), as this is crucial for determining treatment eligibility 2
• EMS should provide pre-arrival notification to the receiving hospital to mobilize stroke team resources before patient arrival 1

Emergency Department Management

• Establish an organized protocol for emergency evaluation of patients with suspected stroke 1
• Perform rapid clinical assessment including neurological examination using standardized tools such as the National Institutes of Health Stroke Scale (NIHSS) 3
• Obtain immediate non-contrast CT scan to rule out hemorrhage and assess for early signs of infarction 3
• Complete CT angiography to identify potential large vessel occlusions 1
• Obtain essential laboratory tests: complete blood count, coagulation studies, electrolytes, renal function, blood glucose 3

Acute Treatment: IV Thrombolysis

• Administer intravenous alteplase to eligible patients as soon as possible after hospital arrival, with a target door-to-needle time of less than 60 minutes in 90% of treated patients and a median time of 30 minutes 1
• Alteplase dosing: 0.9 mg/kg (maximum 90 mg), with 10% given as bolus over 1 minute and remaining 90% as infusion over 60 minutes 1
• Time window for IV alteplase is up to 4.5 hours from symptom onset for eligible patients 4
• Caution: Alteplase dosing for stroke differs from the protocol for myocardial infarction 1

Blood Pressure Management

• For patients receiving alteplase, maintain BP below 180/105 mmHg during and after treatment 1
• If BP exceeds target:
  • Labetalol 10-20 mg IV over 1-2 minutes (may repeat once), or
  • Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h), or
  • Clevidipine 1-2 mg/h IV, titrate by doubling dose every 2-5 minutes (maximum 21 mg/h) 1
• For patients not receiving thrombolysis, only treat BP if systolic >220 mmHg or diastolic >120 mmHg 3

Endovascular Thrombectomy (EVT)

• Consider EVT for patients with proximal anterior circulation occlusions 1
• Standard time window is up to 6 hours from symptom onset 1
• Selected patients may benefit from EVT up to 24 hours based on advanced imaging (CT perfusion or MRI diffusion) 1
• EVT should be offered within a coordinated system of care including:
  • Rapid access to neurovascular imaging
  • Coordination between EMS, ED, stroke team, and radiology
  • Local expertise in neurointervention
  • Access to a stroke unit for ongoing management 1

Post-Acute Monitoring and Care

• Monitor vital signs and perform neurological assessments every 15 minutes during and after alteplase infusion for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours 1
• Monitor temperature at least 4 times daily and treat fever (>37.5°C) with acetaminophen 3
• Monitor oxygen saturation and provide supplemental oxygen only if saturation falls below 94% 3
• Screen for swallowing dysfunction within 24 hours before giving food, fluids, or oral medications 3
• Monitor blood glucose regularly and treat if >180 mg/dL 1, 3

Management of Complications

• For angioedema after alteplase, use a staged response with antihistamines, glucocorticoids, and standard airway management per local protocol 1
• For symptomatic intracranial hemorrhage after alteplase:
  • Stop alteplase infusion immediately
  • Obtain emergent non-enhanced head CT
  • Check complete blood count, coagulation studies, and fibrinogen level
  • Consider cryoprecipitate, tranexamic acid, or other reversal agents on a case-by-case basis 1
• Implement measures to prevent pneumonia, including good pulmonary toileting and early mobility 3
• Avoid indwelling urinary catheters when possible to reduce infection risk 3

Early Secondary Prevention

• Start aspirin (160-300 mg daily) within 48 hours of stroke onset after ruling out hemorrhage 1, 3
• Routine use of anticoagulation (e.g., intravenous heparin) is not recommended for unselected patients 1
• Begin assessment for secondary prevention strategies before discharge 1

Common Pitfalls to Avoid

• Delaying treatment to pursue additional diagnostic studies - time is brain, with an estimated 1.9 million brain cells dying every minute 1
• Using incorrect alteplase dosing protocol (stroke protocol differs from myocardial infarction protocol) 1
• Administering alteplase to patients on direct oral anticoagulants (DOACs) without specialized testing of drug levels 1
• Neglecting swallowing assessment before oral intake, increasing aspiration risk 3
• Failing to monitor for and treat fever, which can worsen outcomes 3
• Overlooking urinary retention, which occurs in 21-47% of patients in the first 72 hours after stroke 3